The ACP Advocate Blog

by Bob Doherty

Friday, January 11, 2013

It’s a rare thing when a single study has the potential to rock the health policy world by directly challenging conventional wisdom, but that’s the case with one published on Sunday in Health Affairs, the go-to journal for policy wonks. It offers the prospect that the much ballyhooed shortage of primary care physicians may not happen after all, because team-based models—the Patient-Centered Medical Home (PCMH) in particular—have found a way to provide good access to primary care for more patients, using fewer clinicians. (The full article is available only to Health Affairs subscribers).

The article specifically found that primary care workforce capacity can be stretched to take care of more patients when primary care physicians work as a team with nurse-practitioners (NP) and physician assistants (PA) in a patient-centered medical home. In which, the non-physicians take care of the majority of patients with routine presenting problems while the physicians take care of patients with more complex diagnostic and treatment challenges. This, by itself, is not a new concept—there is a broad consensus that an “all-hands-on-deck” approach will be needed to meet the current and future demand for primary care. There also is a broad consensus that collaborative teams of physicians, NPs, and PAs can deliver care more effectively and productively than individual clinicians working in their own disconnected silos.

This study, though, goes so far as to say that multi-disciplinary clinical teams in a PCMH, supported by health information technology, have the potential of eliminating primary care physician shortages. How so?

“We show that by implementing partial pooling of patients by two or three physicians and diverting as little as 20 percent of patient demand to nonphysician professionals or using electronic health record–enabled electronic communication, or both, most if not all of the projected primary care physician shortage could be eliminated.”

In other words: the authors believe that electronic communications can substitute for many primary care visits; NPs and PAs working with physician can handle a good proportion of primary care visits, and primary care physicians can handle the rest. They also suggest that PCMHs could make primary care more attractive to physicians, helping to increase supply:

“In addition, the use of nonphysician professionals to deal with more routine problems and the decreased need to respond to urgent requests for care that comes with shared practice can increase the attractiveness of primary care careers for new physicians, adding to the forecast supply. In fact, recent data suggest that this trend may have already begun.”

If you accept their analysis, you would need fewer primary care physicians to meet demand, far fewer than the studies projecting shortages of tens of thousands of primary care physicians.
It is important to note that the authors did NOT say that NPs can replace primary care physicians, nor do their findings support the call for more “independent” NP-run practices.

There are obvious limitations to the study. For one thing, it principally is based on modeling and simulating how models like the PCMH could help meet the demand for primary care more effectively, and then comparing those simulations to accepted studies of primary care physician workforce studies. The authors acknowledge that there are “barriers” to team-based PCMHs that need to be accounted for, but my sense is that the barriers are much greater than they think. For one thing, they may have more confidence in the ability of electronic health records and current electronic communications to substitute for primary care visits than is merited, given the dissatisfaction many physicians have with the current information systems available to them and patient skepticism about them.

They also didn’t address the reality that for the numbers of PCMHs to increase to the point where they could have a major impact on projected workforce demands, there needs to be a sustainable payment model to support such practices.

Nor did they address the reality that many primary care physicians are so frustrated that they are looking for a way to get out of practice altogether, or at least to drastically reduce their patient volume by converting to “concierge” practices. While it is true that more physician practices are making the transition to PCMHs, we are losing more and more, good primary care physicians even as we try to re-invent the system.

It is one thing to model an ideal team-based, technology-enabled multi-disciplinary medical home and how this model might affect the number of patients that can be effectively seen by a practice, and another for policymakers to conclude that PCMHs can “eliminate” the primary care shortage.
At the same time, the study makes an important contribution in illustrating that how we organize and deliver primary care in the United States can make a big difference in the number of physicians and other clinicians we will need. Turning out more primary care physicians just to increase the numbers of them will not be as effective as determining the most effective ways to organize primary care to meet demand, including how to best to combine the skills of all primary care clinicians (physicians, nurses and physician assistants) in accord with patients’ needs and demands, and then build workforce and payment policies to support the most effective models. This is how other parts of the economy have dealt with mismatches between supply and demand. That is, they increase productivity by determining the requisite number of people, with the right combination of skills and technologies needed to meet increased demand using fewer resources. They don’t just produce more of the same.

Bottom-line: I believe that this one study is not enough to throw about the much larger body of research that shows that the United States is facing a growing shortage of primary care physicians. But they are onto something: PCMHs and multi-disciplinary clinical care teams can be a big part of the solution. And we need to begin to integrate analysis of workforce supply and demand with determining how best to organize the delivery of primary care in the United States.

Today’s question: What do you think of the authors’ premise that team-based models that pool primary care physicians with NPs, and that use electronic communications to substitute for some visits, can eliminate the projected primary care physician shortage?

6 Comments
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I look upon this study as a hypothesis only, as Bob's comments reflect, with very little attention to major issues such as funding of this model, physician attitudes and quality measures. Why would I as a physician want to care for only the problematic or most sick patients, accepting the highest risks in job satisfaction, stress, liability -- presumably for the same or less payment as now, spread among more non-physician providers? Another consideration is patient acceptance of PAs & NPs as their "physicians". My experience in present systems heavily dependent on physician extenders (the VA and military medical system), is that significant personal physician involvement is needed for patient satisfaction and extender proficiency. Will this require less primary doctors?

As with most of the proposed reforms, heavy on doctrine, light on real world proof.

The author’s premises are flawed. The amount of non-reimbursed work that a primary clinic does is substantial. To add more non-reimbursed work by managing simple conditions without an appointment would only make the practice less financially viable. There would have to be serious payment reform. With payment reform, the money would have to come from some other part of the system such as hospitals and proceduralists and they would not stand for that.

The number of primary care providers is a moving target but to really affect health care costs you have to have enough primary care providers who have the time and resources to manage well the 20% with complex chronic disease who consume 80% of the health care dollar. The best type of physician to do this is the general internist. Out patient general internal medicine is taking a huge hit. In the past 10 years 30,000 physicians have become hospitalists, most were general internists. Currently about 20% of internal medicine residents will go into general internal medicine, most of whom will become hospitalists so the pipeline for outpatient medicine is only dribbling.

Theoretically without doing hospital care, there should be more time to see outpatients, but that time has been consumed by EHR’s and ever increasing non reimbursed tasks. I see less patients per day now that I have an EHR than before. The authors also have not taken into account the impact of ICD-10, PQRI, and Meaningful use on physician and staff time.

I have to view this concept as self-justification for what many in business view as the future of medicine. I have to also view this as taking a page from pharma’s play book in presenting this as a wide spread idea and those not getting on board as someone not keeping up with the latest in medicine.

Business likes the idea of the doctor/supervisor working for a large corporate owned practice since this gives them the more control over the doctor through such things as EMR’s that can be designed to maximize testing and treatment, thus maximizing revenue. This also allows business to set the protocols for managing risk and the ability to move patients into other practices that may be owned by the corporate entity so as to again maximize profits.

Our current situation should embarrass everyone involved. Doctors must see patients in order to receive a higher payment resulting in a doctor entering a room and without looking up mumbling something about death, test, and return visits. The nurse is then left to explain everything, but the patient conditioned to this doctor interaction, insists on seeing the doctor and anything short is not a proper doctor visit, oh, and why are we not doing imaging studies?

I have seen this first hand as a 93 year old woman with gout, health issues brought on by too much weight, and serious cardiac issues, insist on seeing only the doctor while the PA and the rest of the staff did an outstanding job of listening to her problems and working with social workers to make her life as comfortable as possible. Multiply this across this doctor’s patient panel and the man hours are unbelievable.

Pharma has also learned that flattery and ego can go a long way in shaping physician behavior. There is no shortage of doctors who believe that being a doctor has somehow given them the ability to master other endeavors with out the slightest difficulty. Doctors are not trained as managers, in fact their medical training really works against them in that there are not the management classes, nor the management training they need to work in this new environment. Medical training is rife with abuse that in some sad cases has become generational and institutional.

We need changes in our payment system to allow doctors the time they need to treat those 20% of people with real and serious medical conditions and not churn the rest of their patient panel in order to stay financially viable.

We need changes in HIPPA to allow for the freer flow of information between medical professional and family. Everyone has countless stories of not being given information because they were not on a list, or waiting for a form that never arrives. Great concept, but the unintended consequences have slowed our medical process.

Jay made a great comment some time ago about how nothing happens until the doctor takes pen to prescription pad. There are many in business that want to hold a doctor’s hand, but it is not out of love, it is to take advantage of that relationship.

The benefits of EMR have been overstated. HIPPA constraints and concerns are the greatest impediment to efficiency. Theoretical models fail miserably in the real world of patient care. Good patient care requires time face to face. The system refuses to pay for time spent with patients. Policy makers remain clueless about the real world. Office overhead rises while reimbursement falls. We all know the reality but the policy makers are living in a dreamworld.

It's a provocative study, and I agree with Bob that they are on to something. It is not right to dismiss the hypothesis because the funding won't work -- the notion is that it is a model you build in concert with funding reform.

I think that the right team of docs and NP's could sell this to patients, especially if they manage to offer those things patients are not getting from primary care in the current model:, e.g. access, someone to see them in the hospital when they are sick, attention to mental health.

I would gladly participate in such a practice if my employer was willing to fund it and if we could find a payer to support it.

I think that patient centered medical homes are attractive to payers and to physicians and to NP's and even to staff in a capitated payment environment. Where it has been implemented there is also good evidence that patient satisfaction scores are higher.Implementation of a PCMH involves EHR's. And the more the EHR allows for greater communication between care teams and patients the better they work.I'm quite sure that PCMH's can be implemented badly and be disasters. There are a lot of moving parts. Morning huddles and patient care conferences have to be run well with good team communication. The doctors have to be willing to sometimes be the leaders and sometimes agree to be team members for some parts of care. Patients have to be brought in to feel part of their own team. They have to be comfortable speaking to members of the team who are not the doctor. And the members of the team have to be ready to work at the "top of their license."God I hated writing that cliche.

I think though that PCMH's are going to be an important part of our future health care system.I think also that payment reform that emphasizes capitation will also be part of that.

And I think that this can all be good if we become constructive partners in the change.I think the ACP has already been a leading organization in this reform and has been for over a decade.

EGMN
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